Migraine

Migraine is a common neurological condition characterised by recurrent, often severe headache attacks — typically throbbing or pulsing pain on one side of the head — accompanied by other symptoms such as nausea, vomiting, and heightened sensitivity to light, sound and smell. It is far more than “a bad headache”: migraine is a distinct disorder of the brain's pain-processing pathways, and attacks can last anywhere from a few hours to several days.

Migraine affects people of all ages but is most common between the teenage years and the mid-40s, and occurs roughly three times more often in women than men, largely due to the influence of hormonal fluctuations. For many patients, migraine is not an occasional inconvenience but a recurring disruption to work, family life and daily function — one of the leading causes of disability worldwide among adults under 50.

Types of Migraine

Migraine is not a single, uniform condition — it presents in several recognised forms, and understanding which type you experience helps guide the most appropriate treatment approach.

Migraine Without Aura: The most common form, accounting for the majority of migraine attacks. Headache pain typically develops without any preceding warning signs and lasts between 4 and 72 hours if untreated.
Migraine With Aura: Involves temporary sensory, visual or speech disturbances — such as flashing lights, zigzag lines, or tingling — that appear 10 to 60 minutes before or alongside the headache. Roughly a quarter to a third of people with migraine experience aura, at least some of the time.
Chronic Migraine: Defined as headache occurring on 15 or more days per month for more than three months, with at least 8 of those days having migrainous features. Chronic migraine often develops gradually from episodic migraine and typically requires a more intensive, specialist-led preventive treatment plan.
Menstrual Migraine: Attacks that occur in close association with the menstrual cycle, driven by the natural drop in oestrogen just before menstruation. These attacks can be more severe, longer-lasting, and less responsive to standard acute treatment than migraines occurring at other times of the month.
Vestibular Migraine: A form of migraine in which dizziness, vertigo or balance disturbance is a prominent feature, sometimes with only mild or no headache. It can be mistaken for an inner-ear disorder and often requires specialist evaluation to diagnose correctly.
Migraine With Brainstem Aura / Hemiplegic Migraine: Rarer, more complex subtypes involving symptoms such as slurred speech, double vision, loss of balance, or temporary weakness on one side of the body. These require careful specialist assessment to distinguish from stroke or other neurological emergencies.

How Migraine Develops in the Brain

Migraine is now understood to be a genuine neurological disorder involving changes in brain activity, blood vessels, and pain-signalling pathways — not, as once thought, simply a problem of blood vessels alone. The process generally unfolds as follows:

Brain hyperexcitability: People with migraine tend to have a brain that is more sensitive to change and stimulation, making it more easily triggered by factors such as stress, poor sleep or sensory overload.
Activation of the trigeminovascular system: A network of nerves surrounding the brain's blood vessels becomes activated, releasing inflammatory and pain-signalling chemicals — most notably a protein called calcitonin gene-related peptide (CGRP).
CGRP release and blood vessel changes: CGRP causes blood vessels around the brain to dilate and become inflamed, and sensitises pain nerves, producing the throbbing head pain characteristic of migraine.
Cortical spreading depression: In migraine with aura, a wave of altered electrical activity spreads slowly across the surface of the brain, which is believed to produce the visual and sensory disturbances of the aura phase.

The Four Stages of a Migraine Attack

A full migraine attack can unfold in up to four distinct stages, although not everyone experiences all of them, and not every attack follows the same pattern.

Prodrome: Occurs up to 24 to 48 hours before the headache itself. Subtle warning signs may include mood changes, food cravings, neck stiffness, unusual fatigue, increased thirst or urination, and difficulty concentrating.
Aura: Experienced by a subset of patients, typically lasting 5 to 60 minutes and often occurring just before or alongside the headache. May involve visual disturbances (flashing lights, blind spots, zigzag lines), tingling or numbness, temporary speech difficulty, or muscle weakness.
Headache: The main pain phase, typically lasting 4 to 72 hours if untreated. Classically a throbbing or pulsing pain on one side of the head, worsened by physical activity, and often accompanied by nausea, vomiting, and sensitivity to light, sound or smell.
Postdrome: Sometimes called a “migraine hangover,” lasting up to 24 to 48 hours after the headache resolves. Symptoms may include fatigue, low mood, difficulty concentrating, neck stiffness and continued mild sensitivity to light or sound.

Common Migraine Triggers

Migraine attacks are often set off by specific triggers, though these vary considerably from person to person. Identifying your own personal triggers — often with the help of a headache diary — is one of the most useful steps in managing the condition.

Hormonal changes: Fluctuations in oestrogen around menstruation, pregnancy, or menopause; hormonal contraceptives may also worsen migraine in some individuals.
Sleep disruption: Both too little and too much sleep, as well as irregular sleep schedules or jet lag, are well-recognised triggers.
Stress and its release: Both acute stress and the “let-down” period immediately after a stressful event can bring on an attack.
Dietary factors: Skipped meals, dehydration, alcohol (particularly red wine), excess caffeine or caffeine withdrawal, and certain foods such as aged cheese, processed meats or foods high in MSG.
Sensory stimuli: Bright or flickering lights, loud noises, strong perfumes or smells, and screen glare.
Weather and environmental changes: Changes in barometric pressure, extreme heat or humidity, and high altitude.
Physical factors: Intense physical exertion, poor posture, neck tension, and, in some patients, minor head trauma.

Risk Factors for Migraine

While anyone can develop migraine, certain factors make it more likely:

Family history: Migraine runs strongly in families; having a close relative with migraine significantly raises your own risk.
Sex: Women are approximately three times more likely to experience migraine than men, largely attributable to hormonal influences.
Age: Migraine often begins in adolescence, peaks in frequency and severity during the 30s, and tends to become less frequent from the 50s onward.
Hormonal life stages: Puberty, menstruation, pregnancy and perimenopause are all periods of hormonal flux associated with changes in migraine frequency.
Coexisting conditions: Depression, anxiety, sleep disorders and certain other pain conditions occur more commonly alongside migraine and may worsen its impact.
Obesity: Associated with a higher frequency and severity of migraine attacks, and with a higher risk of episodic migraine progressing to chronic migraine.
Medication overuse: Frequent use of acute pain-relief medication can, paradoxically, increase headache frequency over time.

Possible Complications of Migraine

For most people, migraine — while disruptive — does not cause lasting physical harm. However, without appropriate management, several complications can develop:

Chronic migraine: Episodic migraine can gradually progress to chronic migraine (15 or more headache days a month) in a proportion of patients, particularly where triggers, medication use or coexisting conditions are not well managed.
Medication-overuse headache: Frequent use of acute painkillers or triptans (typically more than 10 to 15 days a month) can lead to a rebound headache cycle that is harder to treat and often requires specialist input to break.
Status migrainosus: A severe migraine attack lasting longer than 72 hours despite treatment, which may require urgent medical attention for pain control and hydration.
Increased stroke risk: Migraine with aura is associated with a modestly increased risk of ischaemic stroke, particularly in women who smoke or use combined hormonal contraceptives — a factor worth discussing with your doctor.
Impact on mental health and quality of life: Living with frequent, unpredictable migraine attacks is strongly associated with higher rates of anxiety and depression, and can significantly affect work, relationships and daily functioning.

How Migraine Is Diagnosed

Migraine is primarily diagnosed clinically — based on your history and symptom pattern — rather than through a single definitive test. Investigations are mainly used to rule out other causes of headache, particularly when certain “red flag” features are present.

Blood Tests: May be used selectively to rule out other conditions that can cause headache, such as infection, anaemia or thyroid dysfunction.
Clinical History and Headache Diary: A detailed account of headache frequency, duration, character, associated symptoms and triggers — often supported by a headache diary kept over several weeks — which forms the cornerstone of diagnosis.
MRI or CT Brain Imaging: Not required for typical migraine, but recommended when headache patterns are atypical, when there are neurological red flags, or when headache begins for the first time after age 50, to exclude other structural causes.
Neurological Examination: A physical examination to check vision, coordination, reflexes and other neurological function, helping to rule out other underlying causes of headache.

Reducing Your Risk: Living Well With Migraine

Migraine cannot always be fully prevented, but a number of everyday measures can meaningfully reduce how often and how severely attacks occur:

Keep a headache diary: Track when attacks occur, along with sleep, meals, stress and other possible triggers, to identify your personal patterns and share them with your doctor.
Maintain a regular routine: Keep consistent sleep, meal and exercise schedules, as irregularity itself is a common trigger.
Stay hydrated and avoid skipping meals: Dehydration and low blood sugar are frequent, easily avoidable triggers.
Manage stress: Regular relaxation practices, exercise, or mindfulness-based techniques can reduce both the frequency and intensity of stress-related attacks.
Limit alcohol and caffeine: Moderate intake and consistent timing can help avoid both direct triggers and withdrawal-related headaches.
Exercise regularly: Regular, moderate aerobic exercise has been shown to reduce migraine frequency over time, although intense exertion can occasionally trigger an attack in some individuals.
Use acute medication appropriately: Take acute treatment early in an attack for best effect, but avoid using it on more than 2 to 3 days a week to prevent medication-overuse headache.
Discuss prevention early: If you are having migraine attacks more than a few times a month, or they are significantly affecting your life, ask your doctor about preventive treatment rather than only treating each attack as it comes.